Sonogram of safety: Ultrasound outperforms the fifth intercostal space landmark for tube thoracostomy site selection.

PURPOSE: Identification of tube thoracostomy insertion location is currently performed using a blind, landmark based approach at either the fifth intercostal space (ICS) or inframammary crease in the midaxillary line. A significant percentage of thoracostomies at this site result in complications. This pilot study aimed to assess whether bedside ultrasound could aid in identifying safer tube thoracostomy insertion sites in emergency department patients. METHODS: Fifty emergency department patients were enrolled in this study. Right and left hemidiaphragms were evaluated with ultrasound at the fifth ICS. Observations were made on if the diaphragm was below, above, or crossed the fifth ICS during an entire respiratory cycle. RESULTS: Eighty-one (95% confidence interval 72-82) of the diaphragms were below, 13 (95% confidence interval 8-21) of the diaphragms were at, and 6 (95% confidence interval 3-12) of the diaphragms were above the location marked using traditional landmark techniques. On the right and left hemidiaphragms, 20% (95% confidence interval 19.9%-20.1%) and 18% (95% confidence interval 17.9%-18.1%) of diaphragms were above or crossing the fifth ICS, respectively CONCLUSIONS: Ultrasound identified a significant number of potential chest tube insertion sites at the fifth ICS that would result in subdiaphragmatic insertion or diaphragmatic injury. Based on this data ultrasound can be used to identify safer insertion sites and reduce thoracostomy complications.

A WINning Technique: The Wire-in-Needle Feasibility Study.

BACKGROUND: Dynamic ultrasound guidance reduces complications associated with central venous catheter placement. However, successful central venous cannulation often remains challenging, particularly in hypotensive patients. The new wire-in-needle (WIN) technique can further increase periprocedural safety. Here, a needle is "preloaded" with a guidewire that is then advanced toward the tip of needle. The vein is then cannulated using long-axis ultrasound guidance. OBJECTIVE: To evaluate the feasibility and safety profile of the WIN technique. METHODS: Medical students, and resident and attending physicians participated in this study. After a brief lecture and practice session on the WIN technique, they underwent a skills assessment evaluating different aspects of both techniques. Participants then completed a survey assessing their prior experience regarding procedural ultrasound, and their assessment of the WIN technique. RESULTS: Sixty clinicians participated. The assessment of both techniques revealed no significant differences in the number of needle redirections, cannulation attempts, number of arterial punctures, or overall dexterity with the procedure. The WIN technique was faster (45.9 vs. 61.5 s, p = 0.0005) than the traditional technique. More participants confirmed the accurate position of the guidewire in the vein (75% vs. 95%, p = 0.002). More than 90% of study participants met the predefined safety aspects of the WIN technique. Almost all participants reported that they plan on using the WIN technique in their clinical practice. CONCLUSION: This study demonstrates that the WIN technique can be learned quickly and easily by clinicians with various levels of training. In this study, using manikins, it was as successful and safe as the traditional short-axis approach.